Arguments for Instituting "General Physicians"

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Abstract

The idea that “general physicians” shall be formulated to act as key agents integrating health care has been proposed and discussed by the government, insurers, and providers with significant difference. Although economic considerations have not been debated, the idea might be connected to reducing referrals or gate-keeping by general physicians. Also it would affect physicians' autonomy.

Purpose of health policy or idea

There has been no life-long divide between general practitioners and specialists in Japan. Most physicians have been trained in teaching hospitals as specialists through undergraduate and postgraduate training, and some of them opt out of hospitals to become practitioners at clinics at their later career stage. Also, a physician has been often supposed to be a specialist of internal medicine, surgery, and whatever. In other words, "general physicians" who have special capability of treating patients other than specialists have not been well recognized. The absence of "general physician" has virtually made it impossible to introduce gate-keeping in the health care system.

 The Medical Ethics Council in charge of qualification of physicians has been discussing a proposal of formulating a new certification for 'general physicians' who are supposed to work as primary interface between people and the health care system and to provide primary care services.

 

Main points

Main objectives

This policy document apparently intends to raise attention to organise serious discussion on re-organizing "general physician" and "general practice" within the health care system in Japan.

Type of incentives

Introduction of financial incentives to the payment system as well as non-financial incentives such as qualification and education and training have been proposed in an abstrac way. All incentives, however, are yet  to be developed.

 

Groups affected

Physicians, Medical Schools, Patients

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

Although the idea is only at its rudimental stage, it implies fundamental changes of physician supply which would need highly innovative policies and arouse great controversy. The above evaluation is no more than a possibility.

Although lack of formal career paths as "general physicians" has been highly dependent on Japanese history of health care, the idea of formulating "general physicians" as key agents of a health care system could be transferred.

Political and economic background

There has been long-standing discussion on a systematic training for becominge "general physicians". The discussion  have never led to specific policies to formulate them. But aging population has been increasing needs to provide more complex services including health (primary and secondary) and social care. With this situation, physicians have been expected to act as agents for integration and/or coordination of those services and efficient service delivery under continuous political and economical pressure to contain costs. To achieve such difficult tasks, it has been proposed that the current absence of "general physicians" should be addressed. 

 

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

The idea that a systematic training is necessary to become "general physicians" is not so new. In fact some academic societies concerned with primary care, family practice or general internal medicine, have learned much from international experiences and developed their training curriculums. However, qualification given by the societies has been voluntary and has no relationship with the public health insurance system.

However, general physicians as agents of resource allocation or "gate-keepers" are a relatively new idea. Probably recent policy debates for increasing efficiency in delivering health services have increased public attention to this idea. Arguments and experiences in the UK health system may have suggested importance of resource allocation by general physicians.

Also, qualification systems in medical and surgical specialities, significantly developed in the last two decades, have established a basis developing a qualification system for a "general physician".

Initiators of idea/main actors

• Government

• Providers

• Payers

• Scientific Community

Stakeholder positions

In 2007 the government announced that further policy development to clarify roles of physicians with their own practice in the health care system(MHLW 2007). The Medical Ethics Council in charge of qualification of physicians started to discuss a proposal of forming a qualification for "general physician" who are able to give consultations to patients with wide-range ill-health and to use available community resources in continuity. Meanwhile a government committee discussing future development of the health care delivery system agreed that physician in community are supposed not only to provide continuous care, but also to collectively provide out-of-hour services, to make referrals to hospital and other community health services, using a whole-person approach (Committee for Health Care Delivery Organizations 2007). The committee also pointed that a systematic training is necessary to raise "general physicians".

 A similar idea has been developed by the Japanese Medical Association. But the idea is concerned with continuity of care rather than with the payment system. But looking at the case above, its position will change accoring to how "general physician" will be formulated in the public health insurance system. The JMA argues that qualification shall be organized within medical professionas and  expressed its opposition to the proposd  idea of formulating a certification for "general physicians" by the government in early  2008(JMA 2008).

Three professional and academic societies concerned with primary care, family care, or general internal medicine merged recently, which may make professional arguments more coherent and united. 

A report, published in March 2008 by a research group organized by the All-Japan Federation of National Health Organizations, an association of public health insurers, recommends formulation of general physicians. Although some physicians and researchers have argued necessity of more systematic training for primary care physicians, this report is noteworthy because it was published by the insurer's organization and it has recommendations of developing a new payment system to primary care physicians(The All-Japan Federation of National Health Insurance Organisations 2008).

The report found the following characteristics common to "general physicians" from the results of a physician survey.  A "general physician" usually:

1.    Treats common diseases and practices primary care;

2.    Can make referrals to specialists and/or specialized health institutions;

3.    Prevents diseases and promotes health in communities;

4.    Has in-depth understandings of everyday life of patients and community people;

5.    Actively provides out-of-hours consultation; and

6.    Actively visits patients' home to give consultations if necessary.

It emphasised necessity of formulating "general physician" and "general practice" as a focused area of medical practice and recommended medical education reform and systematic efforts to facilitate its development, including appropriate payments from public health insurance.

Actors and positions

Government
Ministry of Health, Labour and Welfare	very supportive		strongly opposed
Providers
Japan Medical Association	very supportive		strongly opposed
Payers
The All-Japan Federation Natioal Health Insurers	very supportive		strongly opposed
Scientific Community
Primary Care Researchers	very supportive		strongly opposed

Influences in policy making and legislation

The idea of formulating "general physician" would be relevant to the general principles on payments to physicians that would be reviewed by the government (the Central Social Insurance Medical Council) toward the next revision of the payment rules in 2010.

A newly introduced payment system that physicians receive fixed amount of money per capita every month for providing health services to out-patients with chronic conditions for whom the physician make a long-term care plan [see report on the new Health Insurance for Older Persons Aged 75 and Over] have been so far unpopular among physicians. Probably the implementation process and its consequences would affect formulation of "general physicians".

 

Actors and influence

Government
Ministry of Health, Labour and Welfare	very strong		none
Providers
Japan Medical Association	very strong		none
Payers
The All-Japan Federation Natioal Health Insurers	very strong		none
Scientific Community
Primary Care Researchers	very strong		none

Positions and Influences at a glance

Expected outcome

Re-instituting the "general physician" in the public health insurance system will be so controversial that currently it is impossible to expect any outcomes.

 

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high

If the idea develops to a public policy, it would affect quality, equity and efficiency. However, it is too early to have any opinion currently on the idea.

References

Sources of Information

The All-Japan Federation of National Health Insurance Organisations (2008) Report of a Research Group on Wwhat Communities expect of "General Physicians" .
Committee for Health Care Delivery Organizations (2007) Summary Statements for Further Considerations.
Japan Medical Association(JMA)(2008)The third meeting of heads of prefectural medical associations. JMA News Online, No. 1114(Feb 5, 2008)
Ministry of Health, Labour and Welfare (MHLW) (2007) Health Care Policy: Past, Present and Future.

 

 

Author/s and/or contributors to this survey

Ryozo Matsuda

Ryozo Matsuda is professor for community health and health policy at the College of Social Sciences, Ritsumeikan Univerisity. This report was written when he was a visiting research fellow at LSE Health, London School of Economics and Political Science.

Suggested citation for this online article

Ryozo Matsuda: "Arguments for Instituting "General Physicians"". Health Policy Monitor, April 2008. Available at http://www.hpm.org/survey/jp/a11/1